Citation Nr: 1604352 Decision Date: 02/05/16 Archive Date: 02/11/16 DOCKET NO. 11-19 339 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Fort Harrison, Montana THE ISSUES 1. Entitlement to service connection for gastroesophageal reflux disease (GERD), to include as due to asbestos exposure and/or an undiagnosed illness or other qualifying chronic disability pursuant to 38 U.S.C. § 1117. 2. Entitlement to service connection for fever outbreak to include as due to asbestos exposure and/or an undiagnosed illness or other qualifying chronic disability pursuant to 38 U.S.C. § 1117. 3. Entitlement to service connection for sleep apnea, to include as due to asbestos exposure and/or an undiagnosed illness or other qualifying chronic disability pursuant to 38 U.S.C. § 1117. 4. Entitlement to service connection for sero-negative polyarthritis, to include as due to asbestos exposure and/or an undiagnosed illness or other qualifying chronic disability pursuant to 38 U.S.C. § 1117. 5. Entitlement to service connection for traumatic brain injury, to include as due to asbestos exposure and/or an undiagnosed illness or other qualifying chronic disability pursuant to 38 U.S.C. § 1117. WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD C. Eckart, Counsel INTRODUCTION The Veteran had active service in the U.S. Navy from May 1989 to May 1993, with service in the Southwest Asia Theater of Operations during the Persian Gulf War. These matters initially came before the Board of Veterans' Appeals (Board) from the March 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Fort Harrison, Montana. In June 2013, the Veteran testified at a hearing conducted before the undersigned in Fort Harrison, Montana. A transcript of the testimony has been associated with the Veteran's claims file. In July 2014 the Board remanded this matter for additional development. Such has been completed and this matter is returned to the Board for further consideration. FINDINGS OF FACT 1. Gastroesophageal reflux disease (GERD), did not have its clinical onset in service and is not otherwise related to service including due to asbestos exposure. 2. Residual symptoms of a fever outbreak have been attributed to seronegative rheumatoid arthritis and did not have its clinical onset in service and is not otherwise related to active duty including due to asbestos exposure. 3. Obstructive sleep apnea did not have its clinical onset in service and is not otherwise related to service including due to asbestos exposure. 4. Sero-negative polyarthritis did not have its clinical onset in service and is not otherwise related to service including due to asbestos exposure. Arthritis of any joints was not exhibited within the first post service year. 5. The Veteran does not have chronic residuals of a traumatic brain injury related to service; manifestations of headaches, cognitive and memory problems, are symptoms of other medical problems such as sleep apnea or a psychiatric disorder and a disability manifested by neurological problems is not shown to have had clinical onset in service and is not otherwise related to service including due to asbestos exposure. Neurological problems were not exhibited within the first post service year. 6. The Veteran does not have a qualifying chronic disability of GERD, fever outbreak, sleep apnea, seronegative polyarthritis and traumatic brain injury and pertinent symptoms involving these claimed disorders have been attributed to a diagnosed disability. CONCLUSIONS OF LAW 1. The criteria for service connection for a gastroesophageal reflux disease have not been met. 38 U.S.C.A. §§ 1110, 1117, 1131, 5107; 38 C.F.R. §§ 3.303, 3.317 (2015). 2. The criteria for service connection for chronic residuals of a fever outbreak have not been met. 38 U.S.C.A. §§ 1110, 1117, 1131, 5107; 38 C.F.R. §§ 3.303, 3.317 (2015). 3. The criteria for service connection for a sleep apnea disability have not been met. 38 U.S.C.A. §§ 1110, 1117, 1131, 5107; 38 C.F.R. §§ 3.303, 3.317 (2015). 4. The criteria for service connection for a sero-negative polyarthritis have not been met. 38 U.S.C.A. §§ 1110, 1112, 1117, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.317 (2015). 5. The criteria for service connection for chronic residuals of a traumatic brain injury have not been met. 38 U.S.C.A. §§ 1110 , 1112, 1117, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.317 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist VA has a duty to provide notification to the Veteran with respect to establishing entitlement to benefits, and a duty to assist with development of evidence under 38 U.S.C.A. §§ 5103 , 5103A (West 2002); 38 C.F.R. § 3.159(b) (2015). The duty to notify was partially satisfied prior to the initial RO decision by way of a letter sent to the Veteran in March 2009 that informed him of his duty and VA's duty for obtaining evidence as well as the evidence needed to substantiate his claims for service connection for disorders which included fever and gastrointestinal (GI) disorder due to asbestos exposure, as well as a claim for an unspecified "Gulf War Syndrome" and a list of disorders that included chronic joint pain, insomnia, migraine headaches, memory loss, chronic fatigue, general weakness, seizure like episodes, loss of attention span, uncontrolled spasms in the arms and legs--all claimed as due to environmental hazards in the Gulf War Pelegrini v. Principi, 18 Vet. App. 112 (2004). He was also notified of all elements of the service connection, including the disability-rating and effective-date elements of the claim at that time. Following the March 2010 rating on appeal, the Veteran was informed of the elements of service connection for the enumerated appeal issues in a June 2010 letter. To the extent that this letter was issued subsequent to the initial adjudication of the claim, the claim was re-adjudicated and the Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notice provided. Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, falls upon the party attacking the agency's determination); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). VA also has a duty to assist the Veteran in the development of a claim, which includes assisting the Veteran in the procurement of pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A ; 38 C.F.R. § 3.159. His service treatment records, VA treatment records, and lay statements have been obtained. Several examinations have been done, culminating in the March 2015 VA medical opinion, which is adequate, as it is based on prior physical examination and current review of the evidence of record, including the Veteran's statements, and contains clear findings. Stefl v. Nicholson, 21 Vet. App. 120 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Moreover, VA satisfied the DVB Circular and M21-1, Part IV requirements by obtaining the Veteran's service personnel records and asking the Veteran questions specific to his claimed asbestos exposure in its August 2010 letter. In Bryant v. Shinseki, 23 Vet App 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. 3.103 requires that the Veterans Law Judge who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearing, the Veterans Law Judge outlined the issues on appeal and suggested that any evidence tending to show current disability is related to service would be helpful in establishing the claim. Moreover the Veteran has not asserted that VA failed to comply with 38 C.F.R. 3.103; he has not identified any prejudice in the conduct of the Board hearing. The case was previously before the Board in July 2014, when it was remanded for additional development. In accordance with the remand instructions, addendum VA opinions were obtained in September 2014 and March 2015, and a supplemental statement of the case was issued, most recently in April 2015. Since the record reflects compliance with the prior remand instructions, the Board may proceed with adjudication of the claim. See Stegall v. West, 11 Vet. App. 268, 271 (1998). II. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110 , 1131 (West 2002); 38 C.F.R. § 3.303(a). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Caluza v. Brown, 7 Vet. App. 498, 506 (1995). Where the veteran served continuously for 90 or more days during a period of war, and if arthritis and/or an organic disease of the nervous system became manifest to a compensable degree within one year from the date of the veteran's termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101 , 1112, 1113 (West 2014); 38 C.F.R. §§ 3.307, 3.309 (2015). With chronic diseases shown as such in service, or within the presumptive period after service, so as to permit a finding of service connection, subsequent manifestation of the same chronic disease at any later date, however remote, are service connected unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element for certain chronic disabilities is through a demonstration of continuity of symptomatology. See Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 C.F.R. §§ 3.303(b), 3.309(a). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2002); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran is a Persian Gulf veteran, and as such, the provisions of 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.317 must be considered. Under these provisions, VA is authorized to pay compensation to any Persian Gulf veteran suffering from a "qualifying chronic disability." A "qualifying chronic disability," includes (a) an undiagnosed illness, (b) a medically unexplained chronic multi-symptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) that is defined by a cluster of signs or symptoms, or (c) any diagnosed illness that the Secretary determines, in regulations, warrants a presumption of service connection. 38 U.S.C.A. § 1117(a)(2)(B). To obtain service connection for an undiagnosed illness or combination of undiagnosed illnesses, a veteran needs to show (1) that he or she is a Persian Gulf veteran; (2) who exhibits objective indications of chronic disability resulting from an illness or combination of illnesses manifested by one or more signs or symptoms such as those listed in paragraph (b) of 38 C.F.R. § 3.317; (3) that have become manifest either during active military, naval or air service in the Southwest Asia Theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2011 and (4) that such symptomatology by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317(a). Manifestations of an undiagnosed illness or multisymptom illness include, but are not limited to, fatigue, headache, muscle pain, neurological signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system, sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, or abnormal weight loss. 38 C.F.R. § 3.317(b). Additionally the Veteran has alleged these claimed disabilities as secondary to exposure to asbestos during service. Regarding asbestos-related claims, there is no specific statutory guidance and the Secretary has not promulgated any regulations. Nevertheless, VA has issued a circular on asbestos-related diseases. DVB Circular 21-88-8, Asbestos-Related Diseases (May 11, 1988), provides guidelines for considering compensation claims based on exposure to asbestos. The information and instructions from the DVB Circular were included in the VA Adjudication Procedure Manual, M21-1 (M21-1), Part VI, § 7.21. In December 2005, M21-1, Part VI was rescinded and replaced with a new manual, M21-1MR, which contains the same asbestos-related information as M21-1, Part VI. The Court has held that VA must analyze an appellant's claim of service connection for asbestosis or asbestos-related disabilities using the administrative protocols found in the DVB Circular guidelines. See Ennis v. Brown, 4 Vet. App. 523 (1993); McGinty v. Brown, 4 Vet. App. 428 (1993). The applicable section of Manual M21-1 also notes that some of the major occupations involving exposure to asbestos include mining, milling, work in shipyards, carpentry and construction, manufacture and servicing of friction products such as clutch facings and brake linings, manufacture and installation of roofing and flooring materials, asbestos cement and pipe products, military equipment, etc. High exposure to asbestos and a high prevalence of disease have been noted in insulation and shipyard workers, and this is significant considering that, during World War II, U.S. Navy veterans were exposed to chrysotile, amosite, and crocidolite that were used extensively in military ship construction. Furthermore, it was revealed that many of these shipyard workers had only recently come to medical attention because the latent period for asbestos-related diseases varies from 10 to 45 or more years between first exposure and development of disease. Also of significance is that the exposure to asbestos may be brief (as little as a month or two) or indirect (bystander disease). See Department of Veterans Affairs, Veteran's Benefits Administration, Manual M21-1, Part 6, Chapter 7, Subchapter IV, § 7.21 b. In Dyment v. West, 13 Vet. App. 141, 145 (1999), the Court found that provisions in former paragraph 7.68 (predecessor to paragraph 7.21) of VBA Manual M21-1, Part VI, did not create a presumption of exposure to asbestos. Medical nexus evidence is required in claims for asbestos related disease related to alleged asbestos exposure in service. VA O.G.C. Prec. Op. No. 04-00. In short, with respect to claims involving asbestos exposure, VA must determine whether or not military records demonstrate evidence of asbestos exposure during service, develop whether or not there was pre-service and/or post-service occupational or other asbestos exposure, and determine whether there is a relationship between asbestos exposure and the claimed disease. See M21-1, Part VI, 7.21; DVB Circular 21- 88-8, Asbestos-Related Diseases (May 11, 1988). Factual Background The Veteran contends that he developed sero-negative polyarthritis, sleep apnea, GERD, a traumatic brain injury and a disorder manifested by ongoing fever outbreaks either while he was stationed in, or very soon after, his period of service in the Persian Gulf. The Veteran also attributes the development of these disorders to his in-service asbestos exposure while serving aboard the USS Tuscaloosa. In addition, the Veteran reports that he developed, and has continued to experience, a myriad of unexplained symptoms, to include headaches, fatigue, insomnia, seizure like episodes, and joint pain, since serving in the Persian Gulf War. Because all claimed disorders are based on the same theory of causation, specifically based on Gulf War service and exposure to asbestos, the Board shall discuss the claimed disorders together. The service treatment records reflect complaints of a fever, nasal congestion, sore throat, and body aches. He was assessed with having a viral syndrome in January 1991 and in April 1991. In January 1992, the Veteran presented at sick call with complaints of stomach problems and a headache. He was assessed with either having seasickness or gastroenteritis. At the April 1993 separation examination, the Veteran reported a history of frequent or severe headaches, dizziness or fainting spells, shortness of breath, frequent difficulty sleeping, and depression or excessive worry. He is noted to have denied a head injury on separation, other than treatment at a hospital for a forehead laceration. The service treatment records also include an Asbestos Medical Surveillance Questionnaire dated in September 1992, in which the Veteran endorsed a history of occupational asbestos exposure during his period of service aboard the USS Tuscaloosa. In light of the service treatment records which confirm the Veteran's in-service asbestos exposure, and given that the Veteran's service personnel records document his service aboard the USS Tuscaloosa, and reflect that his military occupational specialty (MOS) was that of electronic/mechanical equipment repairman in service, the Board concedes that the Veteran was exposed to asbestos in service. Service dental records include dental health questionnaires that cited a medical history of fainting, dizziness and nervousness in August 1990 and February 1993. Also in August 1990 he reported sporadic lightheadedness twice a week with consult to medical. Regarding gastrointestinal symptoms an August 1992 DHQ reported a history of ulcers. After service in January 2000, he was treated for sinusitis and URI considered a viral syndrome with ibuprofen prescribed for headaches and myalgias. In September 2001 he was treated for high fever diagnosed as a probable viral illness. The post-service treatment records reflect that the Veteran began presenting at different medical facilities in 2003 with complaints of unexplained symptoms which did not appear to have an etiological origin or explanation. In August 2003 he sought treatment at a private hospital for abdominal pain, loss of appetite, and nausea with a history of headaches, joint pain, trouble breathing and back pain along with fatigue and difficulty concentrating. He was assessed with acute abdominal pain, with another August 2003 record diagnosing possible gastritis. In September 2003 the Veteran initiated treatment at Billings Community Based Outpatient clinic (CBOC), with records from this treatment disclosing a past medical history of peptic ulcer, along with the Veteran thinking he may have Gulf War Syndrome with fluctuating weight, musculoskeletal complaints and joint pain. The assessment included arthralgias, fatigue-TSH, consider depression. He underwent a Persian Gulf Registry examination towards the end of September 2003 with a history of private emergency room visit for peptic ulcer flare up treated with Protinex. His current complaints were of easy fatigability, low energy, daily headaches and vertigo. Examination revealed mild epigastric pain extending to the left lower quadrant, along with nausea. Also noted was weakness of the extremities related to physical demands of the job. Following review of the records and labs, the impression was abdominal pain, fatigue and arthralgias. In January 2009, the Veteran was admitted to Frances Mahon Deaconess Hospital, at which time he reported a history of chills that had lasted twenty-four hours in duration, as well as the onset of hallucinations the night before. He also reported to experience symptoms of nausea, headaches, blurry vision, neck pain, a sore throat and generalized myalgia. During the evaluation, the Veteran explained that these symptoms began in 1993, after he returned home from the Gulf War. After undergoing a series of tests and evaluations, and receiving ongoing follow-up care for the four days he was admitted, the Veteran was discharged with diagnoses of fever and myalgias. The Veteran underwent a neurological consultation at the Fort Harrison VAMC in February 2009, and was evaluated for "Gulf War Syndrome." He had a history of many years of symptoms included memory problems, fatigue, decreased stamina, tingling hands and feet, diaphoresis, temperature fluctuations, random joint pains and muscle aches, occasional visual hallucinations, tremors, insomnia, headaches and dizziness when standing. He also reported "blackout" type episodes about once a year since 1994 with blurred vision, headaches and getting winded to the point of blacking out. He also discussed a recent hospitalization for an episode of facial droop, drooling and not talking with all tests normal except dehydration. Also noted was a history of fevers spiking to 103 degrees, chills and shivering that was treated with antibiotics with rapid improvement. Other components included fatigue and memory decline since 1994 as well as tingling in fingers and toes, joint stiffness, muscle aches, insomnia and flash headaches. After interviewing the Veteran regarding his medical history and taking into account his reported symptomatology, the February 2009 VA neurologist described the Veteran as having a complex presentation and noted that none of the records included brain imaging or workup of the central nervous system. The neurologist also noted that he suspected that the Veteran had chronic insomnia, obstructive sleep apnea, and PTSD. The neurologist suspected that the Veteran's PTSD along with a possible anxiety disorder triggered his "episodes" and noted that there was not a neurological explanation for the episodes. The neurologist also assessed ongoing arthralgia and myalgia, thought to possibly be part of his viral cycle. The symptoms of tingling of the fingers and toes were suspected to be associated with anxiety episodes with non-episodic sensory disturbances to possibly a sign of carpal tunnel syndrome (CTS) or overuse syndrome. He was noted to full fill the criteria for TBI, but was noted to have never had a formal TBI screen. A TBI diagnosis would account for his symptoms such as memory problems, dizzy spells, headaches and poor sleep as they are commonly seen with TBI. Further tests were ordered with EEG normal and a head CT done in February 2009 which diagnosed only bilateral maxillary sinusitis. In March 2009 the Veteran's symptoms of fatigue, weakness, and myalgias were suspected to be a seronegative arthritis, with a rheumatology consult recommended. Among the records from this time addressing these symptoms was one that also noted treatment for a sinus infection with a 103.4 fever reported before he came in for treatment. His medical history included Gulf War Syndrome, and examination disclosed slightly swollen hands, with X-rays of the hands also done in March 2009, which were negative except for evidence of old fracture of the left fifth finger. Also in March 2009, he was diagnosed with sleep apnea by polysomnogram. In July 2009 he was seen by rheumatology for his poly arthralgias with multiple joint pain since 2002. He also had a history of stomach ulcer treatment with Protonix and sleep apnea, periodic fevers spiking to 104-105 with dizziness and blackouts, headaches, syncope, paresthesias of the hands and feet, joint pain, swelling and stiffness, GERD, diarrhea and fatigue. Examination revealed tenderness in the fingers, trapezius and paraspinous muscles. The impression was of polyarthragias and morning stiffness. Further workups were done in September 2009 to address the etiology of his symptoms of joint pain, muscle aches, stiffness and polyarthraglias. The test for rheumatoid arthritis (RA) was negative. A September 2009 letter from the Veteran's rheumatologist described his diagnosis as indeterminate based on labs and expressed doubts that his symptoms actually represented inflammatory arthritis. Thus a trial empiric burst of Prednisone would be tried, and if he failed to respond to it, the diagnosis would be joint pains of undetermined etiology. It was noted that his significant neurological symptoms could not be explained based on a rheumatological condition. The Veteran was afforded a VA examination in October 2009, at which time he reported chronic fatigue, joint pain, fever outbreaks, generalized weakness, insomnia, gastrointestinal symptoms, loss of attention span, migraine headaches, respiratory symptoms and seizure-like episodes that were attributed either to an undiagnosed illness that developed while he served in the Persian Gulf War, or as a result of his in-service asbestos exposure. After interviewing the Veteran regarding his military and medical history, and reviewing his medical records, the examiner noted that these symptoms initially had their onset in 2002. According to the examiner, the Veteran had a complex presentation of symptoms that included spells where he could not talk, poor quality sleep, generalized fatigue, headaches, decreased memory, muscle/joint pain/weakness with intermittent fevers and muscle spasms. The examiner further noted that the Veteran had undergone a neurological evaluation and a series of diagnostic work-ups which resulted in clinical impressions that included chronic insomnia, obstructive sleep apnea and PTSD. According to the examiner, "it is more likely than not that the etiology of [the Veteran's] constellation of symptoms is multifactorial and related to the above condition." The examiner also agreed with statements made by the February 2009 VA neurologist wherein he determined that the Veteran's PTSD and/or anxiety is likely the 'trigger' for his above described 'spells' which could cause shortness of breath, tingling sensations, diaphoresis, tremors, and a blackout affect. The VA examiner further determined that the Veteran likely has a TBI based on his subjective history which would cause dizzy spells, headaches and poor sleep hygiene, as well as a working diagnosis of seronegative rheumatoid arthritis, which would account for the muscle/joint pain he is experiencing. VA records reveal that after being placed on the trial of Prednisone in September 2009, the Veteran responded favorably as reported in February 2010 when his pain was decreased and he could use his hands. There were plans for him to start using Methotrexate (MTX) for his symptoms. Thereafter his diagnosis of seronegative RA was confirmed with a VA primary care (PC) note from May 2010 describing these symptoms and noting that he improved since taking MTX compared to a year ago. Subsequently the VA records confirmed the diagnosis of seronegative RA improved by MTX, including records from November 2010 and February 2011, which also noted the Veteran had issues with low testosterone, which was believed to be causing symptoms of fatigue and malaise. Subsequently he began testosterone injections. The Veteran underwent a VA examination in October 2010 to address whether he has PTSD, with complaints noted to include mood swings, blackout spells where things are not remembered. His medical records were noted to include his complaints of trouble sleeping with initial insomnia, depression and worry, frequent headaches and dizzy/fainting spells on separation from service, as well as post service records documenting problems with episodes of fainting and shaking/loss of consciousness treated post service and attributed as possibly due to anxiety in the prior records. On evaluation for PTSD, the blackout episodes were attributed to flashbacks related to PTSD stressors, and sleep disturbances were attributed to hyperarousal from PTSD as well as with sleep apnea. Concentration issues were also described as part of his PTSD hyperarousal state. He was diagnosed with PTSD, chronic with depressive and dissociative components. The Veteran's claims file was referred to another VA examiner for a medical opinion about his various medical complaints in May 2011, and after reviewing his medical records, the examiner determined that the Veteran's reported symptoms of chronic fatigue, generalized weakness, headaches, insomnia, seizure-like activity, sensitivity to touch, memory impairment/loss, and difficulty concentrating can be attributed to sleep apnea and PTSD. The VA examiner further determined that symptoms attributable to PTSD included chronic fatigue, sensitivity to touch, insomnia, gastrointestinal symptoms, memory impairment, and difficulty concentrating. In addition, the examiner related the Veteran's joint pain to his seronegative rheumatoid arthritis. Based on his review of the service treatment records, there was no objective evidence to suggest that the Veteran was treated for, or diagnosed with obstructive sleep apnea, seronegative rheumatoid arthritis, or a hiatal hernia during service. According to the examiner, the service treatment records were silent for symptoms consistent with sleep apnea, seronegative rheumatoid arthritis or hiatal hernia during active service, and these conditions were identified years after his discharge. Also in April 2012 the Veteran underwent another VA examination for PTSD. The Veteran's history was noted to include his having claimed many physical and some mental symptoms as possible "Gulf War Syndrome" or undiagnosed illness, but which other specialists suggested were caused by mental disorders. The examiner reviewed the records including the February 2009 neurological evaluation suggesting symptoms including fainting and shaking episodes were possibly related to TBI. The Veteran's reported history of inservice head trauma with loss of consciousness was also noted, although it was also noted there was no official record of the claimed head injury. Following review of the evidence and examination of the Veteran, PTSD was diagnosed. Symptoms of this psychiatric disorder experienced by the Veteran included mild memory loss, anxiety, panic attacks (weekly or less often) and sleep impairment including bad dreams and insomnia (noted to be among his hyperarousal symptoms). He also had issues with concentration, mild forgetfulness and irritability noted as part of depressive symptoms associated with PTSD. He also reported blackouts of memory associated with his PTSD, although specifically denying a history of seizure-like spells. The examiner stated that there was no diagnosis of TBI. The examiner also opined that it is more likely than not that symptoms of memory loss, loss of attention and difficulty concentrating are consistent with his diagnosed PTSD. Also the examiner gave an opinion that his PTSD concentrated to his other symptoms including headaches, GI symptoms, insomnia and fatigue. The examiner stated that it is less likely as not that his PTSD contributes to fevers, sensitivity to touch, seizures and generalized weakness and pain. An August 2012 addendum by this examiner suggested that muscle pains are at least as likely as not as a manifestation of PTSD as an anxiety disorder known to create muscle tension related pain. Likewise tingling in the arms and legs are likely as not related to or aggravated by PTSD as an anxiety symptom of re-experiencing traumas. However spasms of the arms and legs were attributed to sleep apnea and less likely than not caused by PTSD. The Veteran was afforded a Gulf War VA medical examination in August 2012, at which time he reported fatigue, headaches, muscle pain, joint pain, neurological signs and symptoms, upper or lower respiratory symptoms, sleep disturbances and gastrointestinal symptoms. According to the Veteran, his symptoms began sometime in 1993, and he continues to experience these symptoms, as well as symptoms such as sensitivity to touch, memory loss, loss of attention, generalized weakness, fever outbreaks, and a tingling sensation that starts in the arms and spreads to the lower extremities. Upon reviewing the Veteran's military records, the VA examiner noted that the Veteran's probability of exposure to asbestos was considered high for VA disability purposes, although the amount of such exposure could not be determined. After reviewing these records and conducting a physical evaluation of the Veteran, which was remarkable for some synovitis of his joints, the examiner determined that all the above-referenced symptoms, either taken by themselves or as a whole, are more likely than not explained by a non-service-connected condition and are not considered an 'undiagnosed illness' or a 'diagnosed medically unexplained chronic multisymptom illness' due to Gulf War Syndrome. According to the examiner, the Veteran has been diagnosed with PTSD, GERD, 'spells', sleep apnea, sero-negative rheumatoid arthritis, low testosterone and a multitude of other medical conditions. The examiner went through all the Veteran's reported symptoms, and attributed each symptom to one or more of these diagnoses. Specifically, he attributed the Veteran's fatigue to his untreated sleep apnea, low testosterone, and rheumatoid arthritis; his headaches to his sleep apnea; his joint and muscle pains to his rheumatoid arthritis; his insomnia to his sleep apnea; his seizure-like episodes, memory loss and loss of attention to his PTSD; and his generalized weakness and fever outbreaks to his rheumatoid arthritis. The examiner did not attribute any of the reported symptoms to either an undiagnosed illness, or a diagnosed medically unexplained chronic multisymptom illness. When asked whether any of the pathological conditions were first incurred in, or manifested during active military service, or otherwise due to or related to an event, injury, treatment or circumstances associated with active service, to include his reported asbestos exposure and/or exposure to any environmental hazards, the examiner concluded that there was no evidence that any of his reported symptoms are related to any events or exposure while he was on active duty. VA treatment records from 2012 through 2013 documented continued follow-up for chronic problems including peptic ulcer, arthralgia, sleep apnea, anxiety, depressive disorder, PTSD, paresthesias, fatigue, myalgia, obstructive sleep apnea, rheumatoid arthritis (RA), and polyarthralgia with RA noted in January 2012. Later in August 2012 he was treated for an episode of amnesia, slurred speech, joint pain, weakness and diarrhea. Examination revealed swollen fingers, wrists and very weak upper extremities. He was assessed with a RA flare up along with a mysterious illness with decreased levels of consciousness, diarrhea and micro-infarcts. An MRI of his head done in September 2012 diagnosed a probable venous angioma of the left frontal lobe. The Veteran's June 2013 hearing testimony expressed his belief that all his claimed disorders were either all due to an undiagnosed illness from his Gulf War service or his asbestos exposure. Regarding his claimed TBI, he also claimed a head injury stemming from an incident he described as having happened aboard the U.S.S. Tuscaloosa in the Persian Gulf when he had to fire a 50 caliber gun at a boat perceived to have unfriendly intentions. He described the recoil from the gun as throwing him against the rail and knocking him out, and reported that he woke with his ears bleeding. Transcript p. 7-10. Regarding his arthritis condition he described it as involving every joint and having started 6 months post service with symptoms of stiffness, pain and cracking joints. He indicated that VA medical personnel linked these symptoms to his Gulf War service. Transcript p. 10-11. Regarding his sleep apnea and GERD, he described symptoms of stopping breathing in his sleep starting around 1995 and GERD also referred to as hiatal hernia, as beginning around 2002. Transcript p. 14-15. Regarding his fever condition, he reported having episodes of fever up to 104-105 degrees with loss of consciousness. Transcript p. 15. Further development was undertaken by the RO after the Board's July 2014 remand determined that the VA examinations to date did not adequately address the issues on appeal, with the May 2011 and the August 2012 examiner having failed to have provided a sufficient explanation as to why the Veteran's disorders were not related to his asbestos exposure and failed to address continuity of symptoms noted in service pertaining to gastrointestinal issues, fever outbreaks and body aches, during his service, and he further reported a history of difficulty sleeping, dizziness or fainting spells, and frequent or severe headaches on his April 1993 medical history report. Thereafter pursuant to the Board's request for clarification of the prior VA examination opinions, a September 2014 addendum to the August 2012 VA examination was drafted by the same examiner who conducted the August 2012 VA examination. Again the examiner confirmed review of the Veteran's e-file and noted that the Veteran was only had minor visits during his service for acute issues and was found to have no chronic issues on his separation exam. He was noted to have been seen in 2003 at the VA and reported only minor symptoms. This was a decade after his separation and the examiner pointed out that at the time he was noted to be attempting to get disability for his varied symptoms. After reviewing the chart, the examiner gave an opinion that it is less likely than not that any claimed condition (sleep apnea, low testosterone, rheumatoid arthritis, traumatic brain injury and GERD) are due to or caused by his service. The rationale was that none of these conditions had their onset during his service, or in the 6 months following his service. As to the etiology of his varied symptoms, the examiner referred to his most recent prior C&P evaluation which outlined these etiologies in some detail. The same examiner again was asked to submit yet another addendum to clarify his prior etiology opinions. In March 2015 an addendum was obtained by the same examiner. The examiner stated that he did review all the above records when he last reviewed this chart, but noted that it appeared it he was specifically asked to address each document sited above. The examiner noted the Veteran's treatment for viral syndrome in January 1991 and April 1991 and noted that the Veteran's separation examination was not consistent with any medical problems developed while in service. The examiner also confirmed review of post service records including the February 2009 neurology exam which showed multiple diagnoses; the summary is all of these problems developed more than 6 months after his service. The October 2009, May 2011 and August 2012 VA examination reports were noted to have reviewed as well. Following such review the examiner gave an opinion that it is less likely as not that the Veteran's sleep apnea, low testosterone, rheumatoid arthritis, traumatic brain injury and GERD had their clinical onset in service or are otherwise related to the Veteran's military service, to include his conceded in-service asbestos exposure. The rationale is that he had no evidence of any of these conditions while in the service or for 6 months after separation. In the March 2015 addendum, the examiner also gave an opinion that all of the above symptoms, taken by themselves or as a whole, are more likely than not explained by a non-SC condition and are not "undiagnosed illness," or a "diagnosed medically unexplained chronic multisymptom illness" due to Gulf War Syndrome. The examiner noted that the Veteran has been diagnosed with PTSD, GERD (peptic ulcer), "spells," sleep apnea (untreated), seronegative rheumatoid arthritis, low testosterone and a multitude of other medical conditions. Specifically, he attributed the Veteran's fatigue to his untreated sleep apnea, low testosterone, and rheumatoid arthritis; his headaches to his sleep apnea; his joint and muscle pains to his rheumatoid arthritis; his gastrointestinal problems to GERD; his insomnia to his sleep apnea; his seizure-like episodes, memory loss and loss of attention to his PTSD; and his fever outbreaks, generalized weakness, sensitivity to touch, and spasms and tingling in his arms and legs to his rheumatoid arthritis. Regarding the fever outbreaks, the examiner noted that there was no documentation in the file to support this claim. The examiner also noted that there was no asbestosis found in regards to respiratory problems including shortness of breath on exertion with no diagnosis of respiratory condition or symptoms. Analysis for GERD Having reviewed the evidence, the Board finds that service connection for GERD is not warranted on any basis of entitlement forwarded by the Veteran in this matter. The preponderance of the evidence reflects that the stomach problems treated during sick call in January 1992 were acute and transitory and resolved without residuals. Where a medical expert has fairly considered all the evidence, his opinion may be accepted as an adequate statement of the reasons and bases for a decision when the Board adopts such an opinion. Wray v. Brown, 7 Vet. App.488, 493 (1995). The Board does, in fact, adopt the opinions of August 2012 VA examiner (based on this examination and the addendums from September 2014 and March 2015) which find that service connection for GERD is not warranted. Since these opinions were based on a review of the pertinent medical history in the electronic record, and were supported by sound rationales, such opinions provide compelling evidence against the appellant's claim. The Board emphasizes that the VA medical expert provided valid medical analyses to the significant facts of this case in reaching the final conclusions. In other words, the VA physician did not only provide data and conclusions, but also provided clear and reasoned analyses, that the Court has held is where most of the probative value of a medical opinion comes is derived. See Nieves-Rodriguez v. Peake, 22 Vet App 295; see also Wray v. Brown, 7 Vet. App. at 493. As the examiner pointed out in the August 2012 examination and clarified in addendums from September 2014 and March 2015, the Veteran did not have post-service treatment for GERD or GERD-like symptoms (including peptic ulcer) for nearly a decade after service. In regards to the GERD potentially having been caused by the conceded asbestos exposure, the examiner in March 2015 stated that it was not related to service including his conceded exposure to asbestos, with the rationale pointing out the lack of evidence of such a condition within 6 months from service. None of the VA or private treatment records or examination reports addressing abdominal pain and other GERD symptoms dating back to 2003 are noted to provide an etiology opinion directly linking these symptoms to any aspect of his service, or refute the August 2012 VA examiner's opinion that his symptoms were acute and transitory in service. Although some of the records are noted to have mentioned "Gulf War Syndrome" with no further discussion clearly delineating defining what reported symptoms (including GERD) actually fit into this syndrome, the overall evidence does not support a finding that the Veteran has an undiagnosed illness related to his active service. In this regard, the Board has considered the provisions relating to service connection for certain disabilities occurring in Persian Gulf veterans. However, the Veteran's gastrointestinal symptoms have now been attributed to a known diagnosis of GERD. This diagnosis has repeatedly been made in the records since 2009. The VA examination from August 2012 examination and the addendums from September 2014 and March 2015 confirmed his gastrointestinal diagnosis to be that of GERD. The Board notes that an October 2009 VA examination described the Veteran as having a complex presentation of symptoms, including gastrointestinal symptoms, which the examiner deemed was multifactorial and likely related to an undiagnosed illness. However since this examination, the gastrointestinal symptoms have been definitely attributed to a known diagnosis of GERD. This renders the provisions of 38 C.F.R. § 3.317 inapplicable. As such, service connection for GERD due to an undiagnosed illness is not warranted. Lay evidence may be competent on a variety of matters concerning the nature and cause of disability. Jandreau v. Shinseki, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The Veteran has claimed that pertinent disability is due to service, including his Persian Gulf War service and asbestos exposure during active duty. The general principle that service in the Persian Gulf and exposure to asbestos can result in disability is commonly known and, therefore, the Veteran's testimony that his gastrointestinal disability, fever, obstructive sleep apnea, arthritis, and neurologic disability are related to service, including exposure to environmental hazards, has some tendency to make a nexus more likely than it would be without such an assertion. However, once the threshold of competency is met, the Board must consider how much of a tendency a piece of evidence has to support a finding of the fact in contention. Not all competent evidence is of equal value. The Board finds the 2012 VA examination report with addenda more probative than the Veteran's statements. The examiner is a medical professional and was able to review the overall record, including the Veteran's history and opinions. The May 2011 VA medical opinion although less thorough in addressing the issues and failing to provide clear rationale is noted to also provide an unfavorable opinion regarding the etiology of his claimed GI condition described by this examiner as showing no evidence of hiatal hernia during service. However this opinion is of limited probative value based on the lack of rationale. Thus the Board adopts the opinions from the August 2012 VA examiner (based on this examination and the addendums from September 2014 and March 2015). See Owens v. Brown, 7 Vet. App. 429, 433 (1995) (holding that VA may favor the opinion of one competent medical expert over that of another when decision makers give an adequate statement of reasons and bases); Guerrieri v. Brown, 4 Vet. App. 467, 473 (1993) ("the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches"). But a medical opinion may not be discounted solely because the examiner did not review the claims file. Nieves-Rodriguez v. Peake, 22 Vet. App. at 304 . The claim must be denied. The preponderance of the competent medical evidence is against a finding that service connection is warranted. Accordingly, the preponderance of the evidence is against this service connection claim. The benefit-of-the-doubt rule does not help, and the Veteran's claim for service connection for a gastrointestinal disability claimed as GERD is denied. See 38 U.S.C.A. § 5107. Analysis for fever outbreak and seronegative arthritis The Board notes that as the evidence indicates that fever outbreaks are as likely as not a symptom on his seronegative arthritis, thus the Board shall address these two issues together. Having reviewed the evidence, the Board finds that service connection for fever outbreak and seronegative arthritis is not warranted on any basis of entitlement forwarded by the Veteran in this matter. The preponderance of the evidence reflects that the fever treated during were acute and transitory and was associated with acute viral syndrome, which resolved without residuals with no evidence of a disorder manifested by fevers shown in service. The earliest post-service evidence of fever is shown in January 2000 several years post service, and associated with a viral syndrome. Although later records are noted to include high fevers treated in February and March 2009, with a sinus infection also diagnosed in March 2009 along with the fever, but with other records from 2009 describing the fevers as being of spontaneous onset. The etiology of the fevers was not clear but further work-up beginning in July 2009 confirmed a diagnosis of seronegative RA that was responsive to treatment. Later the examiner in the August 2012 examination and clarified in addendums from September 2014 and March 2015, gave an opinion that the fever outbreaks were attributed to his seronegative RA, which manifested nearly a decade after service and was diagnosed following the rheumatology workup done in July 2009 through February 2010. Where a medical expert has fairly considered all the evidence, his opinion may be accepted as an adequate statement of the reasons and bases for a decision when the Board adopts such an opinion. Wray, supra. The Board does again adopt the unfavorable opinions of August 2012 VA examiner (based on this examination and the addendums from September 2014 and March 2015) and again notes that these opinions were based on a review of the pertinent medical history in the electronic record, and were supported by sound rationales, such opinions provide compelling evidence against the appellant's claim. The Board emphasizes that the VA medical expert provided valid medical analyses to the significant facts of this case in reaching the final conclusions. See Nieves-Rodriguez, supra. In regards to the fever outbreak and seronegative RA potentially having been caused by the conceded asbestos exposure, the examiner in March 2015 indicated that neither problem was related to service including his conceded exposure to asbestos, with the rationale pointing out the lack of evidence of any of these conditions within 6 months from service. None of the VA or private treatment records addressing his fever outbreaks or RA are noted to provide an etiology opinion directly linking these symptoms to any aspect of his service. Although some of the records are noted to have mentioned "Gulf War Syndrome" with no further discussion clearly delineating defining what reported symptoms (including fevers, joint pains, or other symptoms associated with his seronegative RA) actually fit into this syndrome. In this regard, the Board has considered the provisions relating to service connection for certain disabilities occurring in Persian Gulf veterans. However, the Veteran's fever outbreaks have been attributed to a known diagnosis of seronegative RA. This diagnosis has been confirmed following rheumatology work-up in September 2009, with the Veteran's symptoms of seronegative RA noted to include joint pains and swelling particularly involving the hands, which improved with an empirical burst of Prednisone and was treated with MTX ever since. The VA examination from August 2012 examination and the addendums from September 2014 and March 2015 confirmed his fever, joint pains, muscle pains, generalized weakness, sensitivity to touch, and spasms/tingling in his arms and legs to all be attributable to a known diagnosis of seronegative RA. The Board notes that an October 2009 VA examination described the Veteran as having a complex presentation of symptoms, including generalized fatigue, muscle/joint pain/weakness with intermittent fevers and muscle spasms, which the examiner deemed was multifactorial and likely related to an undiagnosed illness. However since this examination, these symptoms have been definitely attributed to a known diagnosis of seronegative RA. This renders the provisions of 38 C.F.R. § 3.317 inapplicable. As such, service connection for fever and seronegative RA due to an undiagnosed illness is not warranted. The claim must be denied. Again the Board notes that the October 2009 VA examination which appears to suggest the Veteran may have a fever condition and other RA manifestations including generalized fatigue, muscle/joint pain/weakness with intermittent fevers and muscle spasms is as likely as not the result of undiagnosed illness is outweighed by the competent opinions clearly attributing these conditions to a known diagnosis of seronegative RA, provided by the examiner in the August 2012 examination and clarified in addendums from September 2014 and March 2015, with adequate rationale provided. There is no other competent evidence counter to these medical opinions, which is against a finding that service connection is warranted for a fever disorder and seronegative RA. The May 2011 VA medical opinion although less thorough in addressing the issues and failing to provide clear rationale is noted to also provide an unfavorable opinion regarding the etiology of his seronegative RA. Thus the Board adopts the opinions from the August 2012 VA examiner (based on this examination and the addendums from September 2014 and March 2015). See Owens v. Brown, 7 Vet. App. 429, 433 (1995) (holding that VA may favor the opinion of one competent medical expert over that of another when decision makers give an adequate statement of reasons and bases); Guerrieri v. Brown, 4 Vet. App. 467, 473 (1993) ("the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches"). But a medical opinion may not be discounted solely because the examiner did not review the claims file. Nieves-Rodriguez v. Peake, 22 Vet. App. at 304 . Accordingly, the preponderance of the evidence is against this service connection claim. The benefit-of-the-doubt rule does not help, and the Veteran's claim for service connection for a fever outbreak and sero-negative polyarthritis is denied. See 38 U.S.C.A. § 5107. Sleep Apnea Having reviewed the evidence, the Board finds that service connection for sleep apnea is not warranted on any basis of entitlement forwarded by the Veteran in this matter. Although the Veteran reported trouble sleeping on his separation examination in April 1993, he did not receive a formal diagnosis of sleep apnea until he was diagnosed by polysomnogram in March 2009. The evidence also reflects the Veteran had other sleep problems besides sleep apnea including insomnia, which shown to by the evidence to be symptoms of a psychiatric disorder (with the Veteran noted to be service connected for a psychiatric disorder claimed as PTSD). The Board notes that evaluation of the same disability under various diagnoses is to be avoided, and as sleep problems such as insomnia are evaluated under the psychiatric disorder the Board need not address any non-sleep apnea related sleep disorder further. 38 C.F.R. § 4.14. Later the examiner in the August 2012 examination and clarified in addendums from September 2014 and March 2015, gave an opinion that the Veteran's insomnia was attributable to his sleep apnea which manifested nearly a decade after service Where a medical expert has fairly considered all the evidence, his opinion may be accepted as an adequate statement of the reasons and bases for a decision when the Board adopts such an opinion. Wray, supra. The Board does again adopt the unfavorable opinions of August 2012 VA examiner (based on this examination and the addendums from September 2014 and March 2015) and again notes that these opinions were based on a review of the pertinent medical history in the electronic record, and were supported by sound rationales, such opinions provide compelling evidence against the appellant's claim. The Board emphasizes that the VA medical expert provided valid medical analyses to the significant facts of this case in reaching the final conclusions. See Nieves-Rodriguez, supra. In regards to the sleep apnea potentially having been caused by the conceded asbestos exposure, the examiner in March 2015 indicated that this disorder was not related to service including from his conceded exposure to asbestos, with the rationale pointing out the lack of evidence of any of these conditions within 6 months from service. None of the VA or private treatment records addressing his sleep apnea are noted to provide an etiology opinion directly linking these symptoms to any aspect of his service. Although some of the records are noted to have mentioned "Gulf War Syndrome" with no further discussion clearly delineating defining what reported symptoms (including sleep problems) actually fit into this syndrome. In this regard, the Board has considered the provisions relating to service connection for certain disabilities occurring in Persian Gulf veterans. However, the Veteran's sleep related problems including problems difficulty sleeping with fatigue, have either been attributed to a known diagnosis of obstructive sleep apnea, or in the case of insomnia is already being compensated as a symptom of his service connected psychiatric disorder. This diagnosis of sleep apnea has been confirmed following testing done in March 2009. The VA examination from August 2012 examination and the addendums from September 2014 and March 2015 confirmed this diagnosis. The Board notes that an October 2009 VA examination described the Veteran as having a complex presentation of symptoms, including poor quality sleep and sleep apnea, which the examiner deemed was multifactorial and likely related to an undiagnosed illness. However his sleep problems have been definitely attributed to a known diagnosis of obstructive sleep apnea (with some sleep problems also noted to be part and parcel of his psychiatric symptomatology). This renders the provisions of 38 C.F.R. § 3.317 inapplicable. As such, service connection for obstructive sleep apnea due to an undiagnosed illness is not warranted. The claim must be denied. Again the Board notes that the October 2009 VA examination which appears to suggest the Veteran may have a complex multi-system condition including sleep problems/sleep apnea is as likely as not the result of undiagnosed illness is outweighed by the competent opinions clearly attributing these conditions to a known diagnosis of obstructive sleep apnea, provided by the examiner in the August 2012 examination and clarified in addendums from September 2014 and March 2015, with adequate rationale provided. There is no other competent evidence counter to these medical opinions, which is against a finding that service connection is warranted for obstructive sleep apnea. The May 2011 VA medical opinion although also providing an unfavorable opinion regarding the etiology of his sleep apnea, although less thorough in addressing the issue and failing to provide clear rationale. Thus the Board adopts the opinions from the August 2012 VA examiner (based on this examination and the addendums from September 2014 and March 2015). See Owens v. Brown, 7 Vet. App. 429, 433 (1995) (holding that VA may favor the opinion of one competent medical expert over that of another when decision makers give an adequate statement of reasons and bases); Guerrieri v. Brown, 4 Vet. App. 467, 473 (1993) ("the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches"). But a medical opinion may not be discounted solely because the examiner did not review the claims file. Nieves-Rodriguez v. Peake, 22 Vet. App. at 304 . Accordingly, the preponderance of the evidence is against this service connection claim. The benefit-of-the-doubt rule does not help, and the Veteran's claim for service connection for a fever outbreak and sero-negative polyarthritis is denied. See 38 U.S.C.A. § 5107. Analysis for Traumatic Brain Injury Having reviewed the evidence, the Board finds that service connection for TBI is not warranted on any basis of entitlement forwarded by the Veteran in this matter. Although the Veteran reported an incident in his hearing testimony describing the incident in which he sustained a head injury, the evidence is silent for an inservice TBI and he notably denied history of such in his separation examination report of history (although confirming headaches and treatment for a laceration). He also has acknowledged there is no official record of this injury as reported in an April 2012 VA examination for PTSD and elsewhere in the record. The Board further notes that although some of the medical evidence suggested the possibility of a TBI, the preponderance of the evidence is against a finding of a current disability of TBI, with the symptoms initially suggested to be from TBI later attributed to other causes. Of note although the February 2009 neurological evaluation suggested that his symptoms met the criteria for TBI, he had not had a formal TBI screen with subsequent testing including normal EEG and head CT. Likewise the opinion from the October 2009 VA examiner found the Veteran to meet the criteria for TBI based only on the Veteran's subjective history of symptoms. Subsequently the evidence showed no clear indication that the Veteran has an actual disability of TBI, and symptoms such as memory loss and concentration/cognitive impairment and blackout episodes have been determined to be symptoms of a psychiatric disorder per the October 2010 and the May 2012 VA examinations for PTSD. With any claim for service connection (under any theory of entitlement), it is necessary for a current disability to be present. See Brammer v. Derwinski, 3 Vet. App. at 225. Regarding seizure like episodes, the Board notes that this has also been classified by the VA examiner who conducted the VA PTSD examinations in October 2010 and April 2012 as part of the symptomatology of his psychiatric disorder, and in fact the PTSD diagnosis made in the October 2010 included dissociative components. For these separate symptoms attributed to a service-connected psychiatric disorder, the Board again notes that evaluation of the same disability under various diagnoses is to be avoided, and as such symptoms are evaluated under the psychiatric disorder the Board need not address any such symptoms further, other than to note that they are attributed to a disability other than TBI by competent medical evidence. 38 C.F.R. § 4.14. Regarding headaches, these have also been attributed to a non-TBI source. Specifically the examiner in the August 2012 examination and clarified in addendums from September 2014 and March 2015, gave an opinion that the Veteran's headaches which manifested nearly a decade after service are attributable to his sleep apnea which has already been determined by the Board to be non-service-connected. Where a medical expert has fairly considered all the evidence, his opinion may be accepted as an adequate statement of the reasons and bases for a decision when the Board adopts such an opinion. Wray, supra. The Board does again adopt the unfavorable opinions of August 2012 VA examiner (based on this examination and the addendums from September 2014 and March 2015) and again notes that these opinions were based on a review of the pertinent medical history in the electronic record, and were supported by sound rationales, such opinions provide compelling evidence against the appellant's claim. The Board emphasizes that the VA medical expert provided valid medical analyses to the significant facts of this case in reaching the final conclusions. See Nieves-Rodriguez, supra. In regards to a TBI potentially having been caused by the conceded asbestos exposure, the examiner in March 2015 indicated that this disorder was not related to service including from his conceded exposure to asbestos, with the rationale pointing out the lack of evidence of any of these conditions within 6 months from service. None of the VA or private treatment records addressing his claimed TBI symptoms are noted to provide an etiology opinion directly linking these symptoms to any aspect of his service. Although some of the records are noted to have mentioned "Gulf War Syndrome" with no further discussion clearly delineating defining what reported symptoms (including headache and cognitive problems) actually fit into this syndrome. In this regard, the Board has considered the provisions relating to service connection for certain disabilities occurring in Persian Gulf veterans. However, the Veteran's possible TBI symptoms including headache problems have either been attributed to a known diagnosis of obstructive sleep apnea, or in the case of insomnia (other than from sleep apnea) is already being compensated as a symptom of his service connected psychiatric disorder. The Board notes that an October 2009 VA examination described the Veteran as having a complex presentation of symptoms, including migraines, poor attention span and seizure like symptoms, which the examiner deemed was multifactorial and likely related to an undiagnosed illness. However these problems have been definitely attributed to a known diagnosis of obstructive sleep apnea and PTSD. This renders the provisions of 38 C.F.R. § 3.317 inapplicable. As such, service connection for a TBI (or any possible symptoms normally attributed to TBI) due to an undiagnosed illness is not warranted. The claim must be denied. Again the Board notes that the October 2009 VA examination which appears to suggest the Veteran may have a complex multi-system condition including headaches, decreased memory and spells where he could not talk, is as likely as not the result of undiagnosed illness is outweighed by the competent opinions clearly attributing these conditions to known diagnoses including sleep apnea and PTSD, provided by the examiner in the August 2012 examination and clarified in addendums from September 2014 and March 2015, with adequate rationale provided. There is no other competent evidence counter to these medical opinions, which is against a finding that service connection is warranted for TBI. The May 2011 VA medical opinion although also providing an unfavorable opinion regarding the etiology of his claimed TBI, is less thorough in addressing the issue and failing to provide clear rationale. Thus the Board adopts the opinions from the August 2012 VA examiner (based on this examination and the addendums from September 2014 and March 2015). See Owens v. Brown, 7 Vet. App. 429, 433 (1995) (holding that VA may favor the opinion of one competent medical expert over that of another when decision makers give an adequate statement of reasons and bases); Guerrieri v. Brown, 4 Vet. App. 467, 473 (1993) ("the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches"). But a medical opinion may not be discounted solely because the examiner did not review the claims file. Nieves-Rodriguez v. Peake, 22 Vet. App. at 304. Accordingly, the preponderance of the evidence is against this service connection claim. The benefit-of-the-doubt rule does not help, and the Veteran's claim for service connection for a TBI is denied. See 38 U.S.C.A. § 5107. (CONTINUED ON NEXT PAGE) ORDER Service connection for gastroesophageal reflux disease (GERD) is denied. Service connection for fever outbreak is denied. Service connection for sleep apnea is denied. Service connection for sero-negative polyarthritis is denied. Service connection traumatic brain injury is denied. ____________________________________________ THOMAS J. DANNAHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs